Minimally invasive percutaneous plate osteosynthesis versus intramedullary nail fixation for closed distal tibial fractures: a meta-analysis of the clinical outcomes.

En Lin Goh,Gareth G. Jones,Denise Eigenmann,Swathikan Chidambaram,Shaocheng Ma

doi:10.1051/sicotj/2018055

Abstract

Introduction: Minimally invasive percutaneous plate osteosynthesis (MIPPO) has emerged as a viable alternative for the treatment of distal tibial fractures. However, the clinical outcomes of this procedure compared to intramedullary (IM) nail fixation have yet to be established. The present meta-analysis aims to compare the clinical outcomes following MIPPO and IM nail fixation for closed distal tibial fractures.Methods: MEDLINE and EMBASE databases were searched from date of inception to 10th April 2017. Randomized controlled trials (RCTs) comparing MIPPO with IM nail fixation for closed and Gustilo Grade I distal tibial fractures were included. Outcomes assessed included time to union, complications and functional outcomes. Quality and risk of bias of the RCTs were assessed using the Cochrane Collaboration Tool.Results: Five RCTs comprising 497 patients were included. MIPPO was associated with a longer time to union (MD: 1.08, 95% CI: 0.26, 1.90, p = 0.010, I 2 = 84%) and increased risk of wound complications (RR: 1.58, 95% CI: 1.01, 2.46, p = 0.04, I 2 = 0%). Both MIPPO and IM nail fixation had comparable risks of malunion, delayed union, non-union and deep infections, with similar functional outcomes.Discussion: Compared to IM nail fixation, a MIPPO fixation technique for distal tibial fractures is associated with a longer time to fracture union and an increased risk of wound complications. Neither technique demonstrates a clear advantage with regard to risk of malunion/non-union, or functional outcome. Assuming equivalent surgical expertise with both techniques, the results suggest that IM nail fixation is the treatment modality of choice for these challenging fractures.

Highlights

Distal tibial fractures are common injuries affecting individuals of all ages, with an incidence of up to 28 per 10,000 individuals per year [1]
This has led to the increasing use of more soft tissue preserving treatment options such as minimally invasive percutaneous plate osteosynthesis (MIPPO) and intramedullary (IM) nail fixation
Five Randomized controlled trials (RCTs) comprising of 497 patients were included in this meta-analysis (Figure 1, Table 1) [5,16,17,18,19]

Summary

Introduction

Distal tibial fractures are common injuries affecting individuals of all ages, with an incidence of up to 28 per 10,000 individuals per year [1]. Surgical intervention is usually required to realign the fracture, support local tissues and permit mobility of the adjacent joints The management of these fractures remains difficult due to several factors; notably, the limited soft tissue coverage, poor vascularity of the region and proximity to the Traditional open reduction and internal fixation with a plate and screws is associated with a high risk of infection, wound breakdown and delayed union due to the required soft tissue dissection [8]. This has led to the increasing use of more soft tissue preserving treatment options such as minimally invasive percutaneous plate osteosynthesis (MIPPO) and intramedullary (IM) nail fixation. It is unclear which of these techniques is preferable; IM nailing is associated with an increased risk of malalignment and knee pain, while MIPPO is technically challenging, involves more soft tissue dissection and often requires metal work removal following fracture union [6]

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Conclusion